Acute Care Visit
On average, about half of the visits to a pediatrician's office will be for acute care. Such a visit, differs from a well-child or follow-up visit.
More Information: Documenting the visit
The physician documents the well child visit differently from the acute care visit. Payment is based on the documentation. The amount of documentation depends upon the complexity of the case and the extent of the physical examination necessary to make a diagnosis. A carefully constructed set of guidelines used by all doctors in the United States describes the documentation that is needed for billing acute care visits of differing complexity. As a student, you do not need to know this now, but as a resident, you will have to document at the appropriate level for outpatient visits.
For instance, documenting the uncomplicated sick visit (established patient) requires two of the following three key component:
- History: Chief complaint, brief history of present illness (1-3 elements), problem pertinent system review (one system)
- Exam: Expanded problem focused (2-7 body areas or organ systems)
- Decision making: Limited management options, limited amount of data complexity, and low risk of complications.
The typical acute care visit for the sick child only requires a pertinent past and present history, and examination only of the problem-specific organ system(s). In this situation, your preceptor may ask you to take only a brief history and examine only the involved system. Be sure to ask your preceptor if you aren't sure how much history to take and how comprehensive the examination should be.